Gynecologic Oncology 94 (2004) 575 577

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Case Report

Pregnancy after trachelectomy: a high-risk condition of preterm delivery.

Report of a case and review of the literature
Patrick Petignat, a,* Catalin Stan, a Eric Megevand, a and Daniel Dargent b
a

Gynecologic Oncology Service, University Hospitals of Geneva, Geneva, Switzerland

b
Department of Gynecologic Surgery, Hospital Edouard Herriot, Lyons, France
Received 4 August 2003
Available online 2 July 2004

Abstract
Background. Trachelectomy is a conservative but locally radical procedure associated with a high risk of preterm delivery.
Case. A 28-year-old patient with cervical cancer FIGO stage IB1 was treated with laparoscopic pelvic lymphadenectomy followed by
trachelectomy. Three years later, she conceived spontaneously. In consideration of the high risk of preterm delivery, the cervical status was
evaluated by transvaginal ultrasonography. At 16 weeks gestation, we observed the cerclage suture correctly placed at the level of the
internal cervical os and a neo-cervical segment length of 1.5 cm. Thereafter, serial ultrasound measurements showed preservation of the
cervical competence. The patient achieved an uneventful pregnancy and delivered by elective cesarean section at 37 weeks.
Conclusion. Transvaginal scans to evaluate the competence of the neo-cervix may contribute to the management and counseling of
patients after trachelectomy.
D 2004 Elsevier Inc. All rights reserved.
Keywords: Cervical cancer; Fertility; Laparoscopic lymphadenectomy; Pregnancy; Trachelectomy

Introduction

Case report

Women with early stage cervical cancers are usually

managed by radical hysterectomy and have to forego
their desire for future fertility. The issue of having
children after cervical cancer is important as the disease
affects primarily young women and many of them before
childbearing is completed. Vaginal trachelectomy is a
locally radical procedure which allows preservation of
the body of the uterus, but is associated with a high risk
of preterm delivery in pregnancy (Table 1) [1 10].
In a woman with a stage IB1 cervical cancer who
desired to preserve her childbearing potential, we performed laparoscopic pelvic lymph node dissection followed by a radical trachelectomy. Three years later, the
patient had a successful pregnancy and term delivery.

A 28-year-old woman, gravida 3, para 1, with no medical

or surgical history apart from one normal pregnancy and
delivery, presented to our colposcopic clinic for evaluation
of a high-grade squamous intraepithelial lesion identified on
her Papanicolaou smear. A cervical biopsy showed a cervical intraepithelial neoplasia (CIN) III, and the patient was
treated with large loop electrosurgical excision of the transformation zone. Histologic examination showed invasive,
well-differentiated squamous cell carcinoma measuring 9
mm laterally and infiltrated to a depth of 7 mm, without the
presence of lymph vascular space involvement.
The patient was assessed by magnetic resonance imaging of the pelvis and abdomen and examination under
anesthesia to determine the extension of the disease and
was staged FIGO IB1. She was informed of the standard
management in this situation, including radical hysterectomy. However, because the patient strongly desired to
preserve her fertility, she was counseled as to the possibility of radical trachelectomy and informed of the known
risks and complications of the procedure, including the
possibility of compromised fertility.

* Corresponding author. Department of Gynecology and Obstetrics,

University Hospitals of Geneva, Boulevard de la Cluse 30, 1211 Geneva,
14 Switzerland. Fax: +41-22-382-42-24.
E-mail address: patrick-petignat@hcuge.ch (P. Petignat).
0090-8258/$ - see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ygyno.2004.05.039

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P. Petignat et al. / Gynecologic Oncology 94 (2004) 575577

Table 1
Pregnancy outcome and gestational age at delivery after radical trachelectomy
Authors (years)

Number
of patients

Number of
pregnancies

Gestational age
at delivery (weeks)

N (%) deliveries at
z36 weeks gestation

Roy et al. [1]

Martin et al. [2]
Covens et al. [3]
Dargent et al. [4]
Burnham et al. [5]
Shepherd et al. [6]
Alexopoulos et al. [7]
Rodriguez et al. [8]
Schlaerth et al. [9]
Burnett et al. [10]
Total

4
1
4
13
1
8
1
1
4
3
40

5
1
5
20
1
14
1
1
4
3
55

25; 34; 38; 39

27
2 miscarriages; 28; 2 at z36
10 miscarriages or fetal deaths; 10 at z36
37
4 miscarriages; 25; 26; 28; 31; 35; 35; 4 at z36
25
39
24; 26; 32; 38
20; 24; >36
38*

2
0
2
10
1
4
0
1
1
1
22

(50%)
(66%)*
(NA)*
(40%)*

(25%)
(33%)
(58%)*

Miscarriage (<20 weeks gestation); *miscarriages have been excluded; NA = not available.

Laparoscopic pelvic lymphadenectomy was performed

which revealed no lymph node metastases. We then proceeded with radical vaginal trachelectomy, as previously
described [4]. In addition, a single monofilament non-absorbable (1 nylon) suture was inserted into the lower segment
of the uterus to form a cerclage; the knot was hidden in the
isthmo-vaginal suture after a Sturmdorf closure. The vaginal
mucosa was approximated to the isthmic mucosa (squamocolumnar junction) to leave a permeable cervical canal. At the
end of the procedure, the cervical canal was measured and
showed a neo-cervix of 1.2 cm length below the isthmus.
The patient then resumed normal menses; follow-up by
colposcopy and Papanicolaou smear repeatedly tested negative. Three years later, she conceived spontaneously. Transvaginal ultrasound measurement of cervical length was
performed at 16, 20, 24, 28, and 34 weeks of gestation to
assess the stability and competence of the cervix (Fig. 1).
The cerclage placement was located at the internal os with a
cervical length of 1.5 cm throughout the pregnancy.
At 37 weeks gestation, a low transverse cesarean section
was performed under rachis anesthesia, and a live healthy
female child weighing 2700 g was delivered. The mother
and child were discharged 6 days post delivery.

Discussion
The most important issue for the patient and her physician following a treatment for cancer is the cure rate. The

available data in terms of survival after trachelectomy are

scant because the number of patients treated by this procedure remains small. However, it seems that the control of the
disease and survival are comparable to traditional surgical
procedures for early-stage cervical cancer [3,4,6,10].
The second important issue is the fertility and pregnancy
outcome. Even if the body of the uterus is preserved, this
therapeutic approach may alter the reproductive function
and expose those women to a high risk of preterm labor. To
the best of our knowledge, 10 reports regrouping 40 women
and 55 pregnancies have been published in the literature to
date (Medline search: 1966 to April 2003). Among those
women with a pregnancy of more than 20 weeks gestation,
42% delivered z36 weeks gestation (Table 1).
Preterm delivery may occur as a result of lack of
mechanical support of the residual cervix or ascending
infection followed by chorioamnionitis. Given the large
amount of cervix surgically removed, most authors recommend the insertion of a prophylactic cerclage to
provide sufficient mechanical support. A second potentially effective prevention strategy (not performed in our
case) is a total cervico-vaginal occlusion using the Saling
technique, which should be performed between 12 and 14
weeks of pregnancy in an effort to reduce the risk of
chorioamnionitis [4,11].
To date, no data exist in the literature on the cervical
status and competence during pregnancy following trachelectomy. However, it can be assumed that early detection of
preterm labor in these women might be difficult given the

Fig. 1. Endovaginal ultrasonography of cervix after radical trachelectomy (34 weeks gestation). Calipers mark the internal and external os. The distance
between the calipers was considered as the neocervical length (1.5 cm). The cerclage can be seen in cross-sections.

P. Petignat et al. / Gynecologic Oncology 94 (2004) 575577

risk of painless and progressive dilation of their residual

uterine cervix. Usual approaches used to detect preterm
delivery are regular digital cervical examinations, sterile
speculum examinations or ultrasonographic examination.
After trachelectomy, digital cervical and speculum examinations have a limited reliability due to the markedly
modified anatomy caused by the suture of the vaginal
mucosa to the neo-cervix, except in cases presenting with
advanced cervical dilatation or prolapsed of the membranes.
Transvaginal ultrasonographic follow-up may present a
significant advantage over digital or speculum examination
to evaluate the neo-cervix and the endocervical canal, and
to identify women truly at risk of preterm delivery. The
clinician performing the scan should be aware of the
anatomical modifications induced by the surgery, as the
narrowing of the upper part of the vagina due to its
approximation to the isthmic mucosa and should avoid an
excessive pressure on the vaginal probe which could potentially disturb the neo-cervix. In our case, we inserted the
probe slightly into the vagina until it met resistance, visualized the cerclage in the sagittal plane and manipulated the
probe until the entire cervical canal has been visualized.
Neither suture displacement nor significant cervical shortening was observed during the complete pregnancy.
What is the appropriate management if an ultrasonographic diagnosis of cervical incompetence is established?
First and foremost, antenatal interventions should be performed such as a transfer to a facility with a neonatal
intensive unit and the administration of corticosteroids to
the mother to hasten lung maturation. Other approaches
such as the Saling procedure or a second vaginal cerclage
performed in an emergency status would seem to us to be
considered as perilous.
We conclude that serial vaginal ultrasound assessment
of the neo-cervix in patients after trachelectomy allows
the determination of its competence and subsequently
contributes to the management and counseling of the
patient. The effective benefit of this procedure has not
yet been established by evidence-based scientific proof
because of the rarity of these cases, but this attitude may

577

be considered as a likely contributing factor to the efficient

clinical care of these patients.

Acknowledgment
We thank Mrs. Rosemary Sudan for editorial assistance.

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